A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/minute.
Resting respiratory rate of 35 breaths/minute.
The Correct Answer is A
Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Keeping the skin incision moist by periodically wetting the dressing is not the recommended care for a myelomeningocele surgical repair. The dressing needs to be kept dry to prevent infection and promote healing.
Choice B rationale
Removing the tape rapidly from the edges of the dressing during a change is not advised. This could potentially damage the skin and disrupt the healing process.
Choice C rationale
An intact dressing protects the incision from fecal contamination, which is crucial in preventing infection. This statement indicates an understanding of the procedure.
Choice D rationale
While it’s important to keep the dressing dry to ensure easy removal of sutures, it’s not the primary concern. The main goal is to protect the incision from contamination.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
A. Croup
- Rationale: Croup is a condition characterized by a barking cough and stridor (a high-pitched breathing sound), often accompanied by noisy breathing. It is a common cause of respiratory distress in children and can present with symptoms similar to those described.
B. Asthma
- Rationale: Asthma can present in young children with symptoms such as wheezing, shortness of breath, and rapid breathing. However, diagnosing asthma in very young children can be challenging due to the variability of symptoms and the overlap with other respiratory conditions.
C. Bronchiolitis
- Rationale: The child’s symptoms of “fast and noisy breathing” could be indicative of bronchiolitis, a common lung infection in young children. This condition is often preceded by symptoms of a common cold, such as sneezing and a runny nose, which the child had the previous week.
D. Foreign Body Aspiration
- Rationale: Foreign body aspiration should be considered in young children who present with sudden onset of respiratory symptoms, including noisy or rapid breathing, particularly if there is a history of coughing or choking.
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